Internal Medicine Coding Alert

Though still in CPT manual, consult codes have no Medicare value.

The rumors are now official facts. Medicare is deepsixing payment for all consultation codes in 2010. "After years of struggling to differentiate a consult from another E/M service by using the concept of transfer of care, they've just said no" to consult codes, reports Betsy Nicoletti, MA, CPC, author of The Field Guide to Physician Coding.

This change might increase your internists' pay for other E/M services, which have beefed-up value in Medicare's fee schedule. (For more information, see "Here's How E/M RVU Bump Could Benefit Internists" on page 100.)

Check out this primer on the brave new world of E/M coding without 99241-99245 (Office consultation for a new or established patient, which requires these 3 key components: ...) and 99251-99255 (Inpatient consultation for a new or established patient, which requires these 3 key components ...) for Medicare beneficiaries.

Setting will still factor into code choice when reporting consultations in 2010; you'll just be coding for the service with a different set of E/M codes.

Office/Outpatient: "Any physician who sees a patient in the office will need to select either a new or established patient visit [codes 99201-99215], depending on the status of the patient," explains Nicoletti, president of Medical Practice Consulting in Springfield, Vt.

Example: On Jan. 3, 2010, the physician performs an office consult for an established Medicare patient. The physician's notes indicate an expanded problem focused history and examination with low-complexity medical decision making.

Instead of reporting a consult code for this patient in 2010, you'll choose 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...).

Example: On Jan. 3, 2010, the physician performs an office consult for a new Medicare patient. The notes indicate a detailed history and examination with lowcomplexity medical decision making.

Instead of reporting a consult code for this patient in 2010, choose 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires at these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...).

Change your coding when the internist provides consultation services for hospital inpatients.

Inpatient: When a physician performs an initial consult on a patient in the hospital, you should use an initial hospital code (99221-99223), according to Medicare's new consultation guidelines for 2010.

Example: On Jan. 3, 2010, the physician performs a detailed history, comprehensive exam, and straightforward medical decision making on an established Medicare inpatient.

Instead of reporting a consult code for this patient in 2010, you'll choose 99221 (Initial hospital care, per day,for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity ...).

Good advice: "Stop thinking of these codes as admit codes," cautioned Peter A. Hollmann, MD, the AMA CPT Editorial Panel vice chair. They are for initial hospital care. "We should say 'admitting physician' when we mean just that," he continued.

More than one physician can use an initial hospital care code for the same patient. If two physicians from different specialties are both consulting on a patient, both physicians use the initial code for their first encounter.

Multiple physicians using the same hospital codes sounds like a recipe for denials, but that's what Medicare is instructing physician inpatient consultants and care coordinators to do.

Whether carriers will kick out these submissions is contractor specific, Charles E. Haley, MD, MS, FACP, Medicare medical director for Trailblazer Health Enterprises, LLC, told the audience during the E/M session at the 2010 CPT symposium. "If come January you're getting denials, work out the issues with your specific contractor."

Internists who are the admitting physician for the admission will need to use a modifier. "The physician of record will use the initial code with a modifier," stressed Kenneth B. Simon, MD, MBA, CMS senior medical officer, in "Medicare Physician Payment Schedule 2010 Changes and Beyond" at the AMA CPT and RBRVS 2010 Annual Symposium in Chicago All other same day submitted claims for initial hospital care codes will presumably be consults.

What if the main physician doesn't use the proposed modifier AI (Physician of record)? If no one uses the modifier, the claim will be subject to medical review, Simon predicts. "Other claims will be held 'pending review,'" Simon said.

Will using different diagnoses let claims avoid being held up for lack of an admitting physician modifier designation? Unfortunately, separate diagnoses won't make a difference in the initial claim processing phase, Simon said. The codes will, however, help support medical necessity.